A Massive Type IV Hiatal Hernia With Gastric Volvulus and the Complicated Road to Recovery.

Type IV paraesophageal hiatal hernias are rare but carry a significant risk of life-threatening complications, including gastric volvulus, incarceration, and the involvement of other intra-abdominal organs. Pancreatic herniation and associated pancreatitis are exceedingly uncommon. We report the case of a 74-year-old woman with Barrett's esophagus, chronic obstructive pulmonary disease (COPD), and obesity who presented with nausea, vomiting, and abdominal pain after a recent increase in the dose of tirzepatide. Imaging demonstrated a massive type IV paraesophageal hernia with organoaxial gastric volvulus. Initial laparoscopic reduction was aborted due to dense adhesions and a foreshortened esophagus. She subsequently developed progressive herniation involving the stomach, colon, and pancreatic body and tail, and ultimately underwent delayed robotic-assisted repair. The patient's postoperative course was complicated by multiple recurrences, including episodes of volvulus, duodenal obstruction, and mild pancreatitis. She ultimately required open repair with mesh reinforcement and gastropexy after unsuccessful endoscopic detorsion. Despite temporary improvement, she later developed recurrent herniation and severe gastroparesis, likely secondary to injury to the vagal nerve. This report highlights the complexity of managing massive type IV paraesophageal hernias, particularly with multi-organ involvement and recurrence. Even with advanced surgical approaches, recurrence and long-term complications remain significant challenges.